Between sanity, sexuality, and sentences: Understanding intimacy in forensic patients

Background:

Serious mental illness (SMI) has a significant and extensive impact on overall development, quality of life, and sexual functioning. Sexual functioning and mental health (MH) are interconnected. Sexual functioning and sexuality—including sexual knowledge, sexual development, sexual health and sexual experiences—has been explored in many populations, including the Australian general and prisoner populations. However, little is known of the sexual function of community-based forensic patients (FPs).  FPs endure at the intersection between the MH and the justice system. These patients often have a SMI and have committed indictable offences, creating a situation where both their health and their custodial sentences are managed within the restrictions of relevant MH legislation. The gap in knowledge around this group’s sexual health impacts on the provision of comprehensive MH care endorsed under the Recovery Framework.

Methods:

The study was conducted in three face-to-face phases with community-based FP in south-east Queensland. The first two phases informed the final qualitative phase.

Phase 1: Survey - quantitative data on sexual knowledge.

Phase 2: Survey - quantitative data on sexual experiences.

Phase 3: Semi-structured interviews - current and ideal sexual functioning, and participants perceived barriers and attitudes to MH clinicians’ involvement in patients’ sexual health needs.

Of the Queensland adult community-based forensic patient population, 43 males and 7 females participated. Most were Australian born, with a mean age of 41.2 years and proficient in English. All were prescribed psychotropic medications for SMI, with most ‘in remission’.

Results:

Robust sexual education, mainly by the educational system, was lacking. Deficits in sexual knowledge were evident in all domains: physiology, sexual intercourse, pregnancy, sexually transmitted diseases, contraception, and sexual terminology. Quantitative results indicate that sexual development was on par until the teenage years, before rapidly declining.

Overall, the results showed the participants had less sexual encounters, longer periods between sexual encounters, and had significant sexual difficulties compared to other populations. Sex toys were seldom used, with no participation in alternative sexual practices, including role-play or swinging. Risky sexual behaviour, including low contraception use, was evident in this group. Most of the participants found sex pleasurable, wished to have more sex, and engaged in frequent sexual fantasies. Most preferred daily sex stimulation and experienced positive reinforcement after sex and agreed that improvement in their sexual experiences resulted in a better quality of life.

Qualitatively, participants were generally sexually inactive, although eager to engage in sexual activity. Barriers to achieving sexual health satisfaction included: active MH symptoms, limited social networks, poor communication skills, and medication-related sexual dysfunction. The participants strongly endorsed the role of MH clinicians in assisting them to improve their sexual functioning and quality of life.

Discussion and Conclusion:

Enhancing forensic clinicians' awareness of gaps in the assessment, treatment, and evaluation of sexual functioning could improve clinical competencies and inform the development of interventions that promote safe and fulfilling sexual experiences for FPs.  Empirical evidence should guide policymaking, clinician education, and clinical interventions while shaping future studies aimed at supporting recovery, optimising sexual health, and ultimately enhancing the quality of life (QOL) for FPs.

The normalcy and legitimacy of sexual expression as fundamental human experiences should be recognised in FPs. Sexual functioning has a valuable role in procreation, experiencing pleasure, fostering intimacy and emotional connection, and enhancing self-worth and individuality. Acknowledging these aspects is essential for supporting the well-being and rehabilitation of patients. 

Dr Elnike Brand is a fully registered Specialist General Adult and Forensic Psychiatrist with AHPRA and a fellow of RANZCP. She holds a medical degree from Pretoria and specialist qualifications in Forensic Psychiatry. Dr Brand has completed impairment evaluation training in QLD and NSW and holds postgraduate certificates in child custody and ADHD assessment. A PhD scholar at UQ, she is also a member of the Society of Australian Sexologists. She has extensive experience across community, custodial, and forensic settings, and provides medicolegal reports and expert evidence. Dr Brand is Director of Specialist Mind Care. Full CV available on request. Her full curriculum vitae is available upon request.